Provider Demographics
NPI:1518948702
Name:HARTVILLE INTERNAL MEDICINE PA
Entity Type:Organization
Organization Name:HARTVILLE INTERNAL MEDICINE PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:AMIN
Authorized Official - Middle Name:YOUSSEF
Authorized Official - Last Name:KHALIL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:330-877-9388
Mailing Address - Street 1:855 W MAPLE ST
Mailing Address - Street 2:SUITE 130
Mailing Address - City:HARTVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44632-9668
Mailing Address - Country:US
Mailing Address - Phone:330-877-9388
Mailing Address - Fax:330-488-2907
Practice Address - Street 1:855 W MAPLE ST
Practice Address - Street 2:SUITE 130
Practice Address - City:HARTVILLE
Practice Address - State:OH
Practice Address - Zip Code:44632-9668
Practice Address - Country:US
Practice Address - Phone:330-877-9388
Practice Address - Fax:330-488-2907
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HARTVILLE INTERNAL MEDICINE PA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-11-07
Last Update Date:2012-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH101425OtherBLACK LUNG
OH000000213674OtherANTHEM
OH2526476Medicaid
OH=========001OtherMEDICAL MUTUAL
OH2526476Medicaid
OH101425OtherBLACK LUNG
OHHA9318531Medicare PIN